Delay in seeking medical attention for heart attack changes life

Don’t delay in seeking medical attention if you are concerned about a heart attack

Time is muscle if the heart is not getting the proper blood flow to the muscle, the muscle dies. The muscle is unable to repair itself and eventually that portion that dies is converted to scar tissue. Scar tissue is not flexible and doesn’t push the blood out of the chamber of the heart. If the blood is not pushed through the heart the amount circulating through the body is reduced. This can lead to serious heart related complications, including congestive heart failure, angina, shortness of breath and limited ability for physical activity.  This creates complications for many things including returning to work, or causing early retirement as the article above discusses.

Discomfort, squeezing, pressure, heaviness, aching…in the chest, between the shoulder blades, the neck, jaw or down the arms are the classic symptoms. If accompanied  by shortness of breath, nausea, profuse sweating the condition is all the more urgent. Chew up 325mg aspirin and call 911.

Resource for Heart Failure


Below is some of the content from the above listed web site. It is a great resource for helping heart patients to understand the warning signs of heart failure and the actions to take. If you are a heart patient, or the significant other/caregiver take the time to review this site. It is important sometimes the symptoms sneak up on you.



Heart failure can be managed well with the right treatment and lifestyle adjustments, as recommended by your doctor or nurse. However, it is important to monitor all your symptoms on a regular basis as heart failure can progress slowly.


You can use the list on the left or any of the links below to learn more about the symptoms you should be monitoring and what to do if they get worse.


You should call for help immediately if you experience:


Persistent Chest pain that is not relieved by glyceryl trinitrate (GTN / nitroglycerin)

Severe and persistent shortness of breath



You should inform your doctor as soon as possible if you experience:


Increasing shortness of breath


Frequent awakenings due to shortness of breath


Needing more pillows to sleep comfortably


Rapid heart rate or worsening palpitations


And you should discuss any of the symptoms below with your doctor or nurse.


Rapid weight gain


Progressive swelling or pain in the abdomen


Increased swelling of the legs or ankles


Loss of appetite/nausea


Increasing fatigue


Worsening cough


To help you monitor your symptoms, please click on the links below to find useful resources that you can download, print and fill in. You can then take these with you when you see your doctor or nurse and discuss your symptoms.


Symptom and event diary


Monitoring your heart failure chart


Warning signs leaflet




Depression and Heart Conditions

Depression is common in heart patients. Most studies show 2 out of 3 patients will experience depression. Does depression cause heart disease or does heart disease cause depression? Probably both. We all have ups and downs, however when one finds them overwhelming and debilitating it is time to get help. According to the National Institute for Mental Health the following are the symptoms of depression:

Signs and symptoms include:

  • Persistent sad, anxious, or “empty” feelings
  • Feelings of hopelessness or pessimism
  • Feelings of guilt, worthlessness, or helplessness
  • Irritability, restlessness
  • Loss of interest in activities or hobbies once pleasurable, including sex
  • Fatigue and decreased energy
  • Difficulty concentrating, remembering details, and making decisions
  • Insomnia, early-morning wakefulness, or excessive sleeping
  • Overeating, or appetite loss
  • Thoughts of suicide, suicide attempts
  • Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

One of the best things a person who is suffering from depression can do is to get daily exercise. Yet it is one of the hardest things to do when depressed. I would encourage patients to at a minimum schedule themselves 10 minutes per day of exercise. I know it is a very short duration, but it is a starting point. We build from there.  If you are a significant other of someone you suspect is depressed, don’t nag them to exercise, rather help them to engage in it. Offer to go for a walk, or go to the gym together.

For many suffering from depression winter can be especially difficult. The holidays may trigger episodes, a change in healthy eating habits to the holiday party foods, a change in exercise habits due to weather changes, getting out and socializing less due to weather, loss of loved ones,  and seasonal effective disorder can all be a catalyst for symptoms to worsen. If you note this contact your healthcare practitioner, consider counseling, increasing exercise, getting sunlight every day, and/or medications. It is important because if depression isn’t treated often heart disease worsens.

Seasonal affective disorder (SAD), which is characterized by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not get better with light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy



Heart disease patients who have anxiety have twice the risk of dying from any cause compared to those without anxiety, according to new research in the Journal of the American Heart Association.

Patients with both anxiety and depression have triple the risk of dying, researchers said.

Many studies have linked depression to an increased risk of death in heart disease patients. However, anxiety hasn’t received as much attention. Studies show that depression is about three times more common in heart attack patients. The American Heart Association recommends that heart patients be screened for depression and treated if necessary.

Depressed heart disease patients often also have anxiety, suggesting it may underlie the risk previously attributed solely to depression. It’s now time for anxiety to be considered as important as depression, and for it to be examined carefully.”

In the study, 934 heart disease patients, average age 62, completed a questionnaire measuring their level of anxiety and depression immediately before or after a cardiac catheterization procedure at Duke University Medical Center. Patients had anxiety if they scored 8 or higher on a scale composed of seven common characteristics of anxiety, with each item rated from 0 to 3 (range of possible scores: 0-21). Depression was measured using a similar scale composed of seven symptoms of depression.

Researchers, after accounting for age, congestive heart failure, kidney disease and other factors that affect death risk, found that 90 of the 934 patients experienced anxiety only, 65 experienced depression only and 99 suffered anxiety and depression. Among 133 patients who died during three years of follow-up, 55 had anxiety, depression or both. The majority of deaths (93 of 133) were heart-related.

Researchers measured anxiety and depression during cardiac catheterization because levels better reflected how patients normally handle stressful situations. Anxiety and depression each influence risk of death in unique ways. Anxiety, for example, increases activity of the sympathetic (adrenaline-producing) nervous system that controls blood pressure.

People who worry a lot are more likely to have difficulty sleeping and to develop high blood pressure. The link between depression and mortality is more related to behavioral risk factors. Depression results in lack of adherence to medical advice and treatments, along with behaviors like smoking and being sedentary.

Future studies should test strategies to manage anxiety alone and with depression in heart disease patients.

Anxiety reducing medications combined with stress management could improve outcome for patients with just anxiety, whereas patients with anxiety and depression may need a stronger intervention involving more frequent outpatient monitoring and incentives to improve adherence.

Slowly getting there, comments from our cardiac health innovators?

Sodium and fluid retention

How Sodium causes fluid retention

The job of the kidneys is to filter the excess sodium into the urine so that the body can get rid of it. Many with heart disease and diabetes kidneys cannot handle all the extra work. The kidneys become less efficient at filtering the blood stream. This causes excess sodium to enter the bloodstream. Sodium attracts water to it and effect known as being osmotic. Water follows the sodium  and is drawn into the bloodstream. Excessive salt keeps the circulatory volume higher than it should be, creating and increased pressure in the blood stream and pressing on the blood vessel walls. The stress of the pressure on the walls creates thickening and narrowing of the vessel, leaving less space for the fluid in the blood vessels and raising resistance.  The body then requires higher pressure to move blood to the organs. The heart has to pump against this high pressure system.

I equate it to trying to blow up one of those kids balloons that is turned into animal shapes. They are really tough to blow air into, your cheeks get really sore – this is the resistance of air, similar to the resistance pressure of blood in the arteries. If you stretch the balloon (relax the arteries) then there is less resistance in blowing up the balloon (filling the artery with blood). Twenty percent  of the blood pumped from the heart goes  first to the kidneys.  High blood pressure within the kidneys cause  damage to the heart and to the vascular system in the kidneys. Salt makes you thirsty so limit salty foods, especially if on a fluid restriction.

I once had a patient who lost 45 lbs simply from adhering to low sodium diet. He had a very weak heart with only 10% ejection fraction meaning very limited pumping ability. So a weak heart and sodium in the diet made him retain fluid more than most. He began to measure and count sodium with every meal for a few months and was shocked by how much sodium he consumed even though he thought he ate pretty healthy. By reading labels, doing the math every day and making changes such as eating out less, ordering special, reviewing his medication he lost the fluid and added years to his life, not to mention the improved quality of life with less shortness of breath and fatigue by easing the workload of the heart.


According to the American Heart Association, eating more than the recommended 1500 milligrams a day puts you at direct risk of high blood pressure. Yet in America we consume an average of 3400 milligrams a day; more than twice what we should. While people with hypertension, heart and kidney disease are always advised by doctors to eat less salt, the AHA wants all of us to do this, whether or not our blood pressure is currently in the normal range. So if you are cooking or know the cook for pass this info on!


When holiday meal are  upon us  remind heart patients of being acutely aware of the sodium content in foods. The holiday meal contributes to many heart patients having increased symptoms of  high blood pressure, congestive heart failure, fluid retention, shortness of breath. The holiday meals  can be the culprit. Traditional foods like the turkey are often injected with  approximately 8% solution sodium to enhance moistness and flavor. If you read the ingredients you will often note: turkey broth, salt, sodium phosphates, sugar & flavoring. Then many a cook will soak the already salt injected turkey in a brine solution or salt it well, prior to cooking. The turkey alone gets many into trouble, then you add pre-packaged stuffing, broth, or use canned mushroom soups in casseroles. Did I mention the relish tray with pickled foods?


A little extra salt in or on your holiday foods makes a difference.

1 teaspoon salt = 2131 mg sodium                                          1/2 teaspoon salt = 1066 mg sodium

1/4 teaspoon salt = 533 mg sodium                                        1/8 teaspoon salt = 266 mg sodium

75 mg—the average sodium content of 3 ounces fresh, unsalted beef, turkey, chicken, pork

240 mg sodium in 3 ounces self-basting frozen turkey, cooked (that’s without the gravy!)

580 mg sodium in 3 ounces frozen fully cooked baked turkey

820 mg sodium in 3 ounces honey baked ham

Bread is a major sodium contributor if you eat more than a couple of pieces a day unless you buy special low sodium bread. A slice (1 ounce) of loaf bread has 150 to 200 mg sodium—not including salted butter or other spreads or toppings. Consider using a bread maker to make a low sodium recipe.

Skip the gravy! But if you must go for low or reduced sodium gravy instead of regular salted gravy which has more than 300 mg sodium for 1/4 cup.                                                                                                                                                              

Measurements and labels of sodium

  •  1/4 teaspoon salt= 600 mg sodium
  • 1/2 teaspoon salt= 1,200 mg sodium
  • 3/4 teaspoon salt=1,800 mg sodium
  • 1 teaspoon salt= 2,300 mg sodium
  • 1 teaspoon baking soda =1,000 mg sodium
  • Sodium-free: Less than 5 milligrams of sodium per serving
  • Very low-sodium: 35 milligrams or less per serving
  • Low-sodium: Less than 140 milligrams per serving
  • Reduced sodium: Sodium level reduced by 25%
  • Unsalted, no salt added, or without added salt: Made without the salt that’s normally used, but still contains the sodium that’s a natural part of the food itself.

Names for salt

  • sodium alginate
  • sodium ascorbate
  • sodium bicarbonate (baking soda)
  • sodium benzoate
  • sodium caseinate
  • sodium chloride
  • sodium citrate
  • sodium hydroxide
  • sodium saccharin
  • sodium stearoyl lactylate
  • sodium sulfite
  • disodium phosphate
  • monosodium glutamate (MSG)
  • trisodium phosphate
  • Na

Some drugs contain high amounts of sodium.

Need an antacid after that holiday meal?  Watch out there is excess sodium there too. Carefully read the labels on all over-the-counter drugs. Look at the ingredient list and warning statement to see if the product has sodium. A statement of sodium content must be on labels of antacids that have 5 mg or more per dosage unit (tablet, teaspoon, etc.). Some companies are now producing low-sodium over-the-counter products. If in doubt, ask your healthcare practitioner or pharmacist if the drug is OK for you.


End of Life Choices

For many with heart disease it is a battle to remain living, yet know you are dying from a diseased heart. Many don’t discuss with their healthcare practitioners the choices and decisions they have when it comes to fighting to stay alive or choosing to let go. Over my career I have watched many patients suffer trying numerous medical interventions and medications only to have a horrible quality of life. In the medical community we see patients literally beg their doctors to let them pass, and yet the physician urges them to fight on with the newest surgery or medication. These are issues that heart patients should be able to discuss with their families and health care providers early on, so everyone has a clear picture of your wishes.

When it comes to end of life you have choices

Your choices

  • Stop treatment that prolongs your life. Instead, receive only treatment that focuses on your comfort and quality of life.
  • Don’t stop treatment that prolongs your life.

Key points in making your decision

  • If there is a good chance that your illness can be cured or managed, your doctor may advise you to first try available treatments. If these don’t work, then you might think about stopping treatment.
  • If you stop treatment, you may still receive care that focuses on pain relief, comfort, and the quality of your life. This is called palliative care  or hospice care.
  • A decision to stop treatment that keeps you alive doesn’t have to be permanent. You can always change your mind if your health starts to improve.
  • Even though treatment focuses on helping you live longer, it may cause side effects that can greatly affect your quality of life and your ability to spend time with your family and friends.
  • If you still have personal goals that you want to pursue, you may want treatment that keeps you alive long enough to achieve them.

Reasons to have life support:

  •  You need life support because of an emergency that is not related to your illness.
  •  Life support may help you return to your  normal activities.
  •  Your quality of life is good and you have a sudden event that requires life support..
  •  You could recover well from the event.

Reasons  not to have life support

  • You have other long-term health problems that make it less likely that you will benefit from life support.
  • The risks of life support outweigh the benefits.
  • Life support will not help you return to your normal activities or to a level of activity you would like to have.
  • You want a calm, peaceful death, and you do not want to spend the rest of your life on a ventilator

Physician Orders for Life Sustaining Treatment

I had a patient who wanted to die in cardiac rehabilitation. He expressed this wish often. He was adamant he did not want any life-sustaining treatment, however in rehab we were bound to comply with our standard of care which meant life-sustaining treatment, CPR and defibrillation until the patient was received in the hospital emergency room where his advanced directive were on file. This is the case in most hospital or outpatient settings, even EMS has an obligation to respond unless one has a POLST form visible in their house or on their person.   The only legal way for me to respect his wishes was for him to have a POLST form filled out and on file in the rehab department, and as a card he carried and a form posted in his home. What is POLST. It is an agreement made between  you and your physician about what life-sustaining treatment you with to have. To read more about this visit the link:

Do you have an ICD?

Heart patients who have an ICD need to consider and  discuss the difficult issue of ICD deactivation as  clinical status worsens and death is near. Unfortunately, “clinicians and patients rarely engage in discussions about deactivating ICDs, and most devices remain active until death” and “most patients are not even aware that deactivation of the shocking function is an option.

Palliative care relieves the symptoms of  disease, such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite and difficulty sleeping. It helps you gain the strength to carry on with daily life. It improves your ability to tolerate medical treatments. And it helps you have more control over your care by better understanding your choices for treatment options. Including decision-making and coordinating of issues such as ICD deactivation.

The point of palliative care is to relieve suffering and provide the best possible quality of life for both you and your family.

Palliative and hospice care is often left for the very end of life. By initiating palliative care earlier it reduces emergency department visits and improve symptoms, which increases time at home and quality of life.

Palliative Care
Palliative care teams are made up of doctors, nurses, and other professional medical caregivers, often at the facility where a patient will first receive treatment. These individuals will administer or oversee most of the ongoing comfort-care patients receive. While palliative care can be administered in the home, it is most common to receive palliative care in an institution such as a hospital, extended care facility, or nursing home that is associated with a palliative care team. There are no time restrictions. Palliative care can be received by patients at any time, at any stage of illness whether it be terminal or not.


Hospice programs far outnumber palliative care programs. Generally, once enrolled through a referral from the primary care physician, a patient’s hospice care program, which is overseen by a team of hospice professionals, is administered in the home. Hospice often relies upon the family caregiver, as well as a visiting hospice nurse. While hospice can provide round-the-clock care in a nursing home, a specially equipped hospice facility, or, on occasion, in a hospital, this is not the norm. You must generally be considered to be terminal or within six months of death to be eligible for most hospice programs or to receive hospice benefits from your insurance.

Our health care system faces the challenge of allocating limiting resources to an aging population. The focus is on solutions that improve patient quality of life while minimizing unnecessary expenses.  Integrating palliative care into the health care system at an earlier time helps quality of life and reduced cost associated with the disease process.